Background: Absence of knowledge of pregnancy-related pelvic girdle pain (PPGP) has prompted the start of a large cohort study in the Netherlands. The objective of this study was to investigate the prevalence and incidence of PPGP, to identify risk factors involved in the onset and to determine the prognosis of pregnancy-related pelvic girdle pain.

Rationale, aims and objective Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting. Method The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible. Results A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers. Conclusions Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

Introduction Segmentation of the high-need, high-cost (HNHC) population is required for reorganizing care to accommodate person-centered, integrated care delivery. Therefore, we aimed to identify and characterize relevant subgroups of the HNHC population in primary care by using demographic, biomedical, and socioeconomic patient characteristics.

Background High-need, high-cost (HNHC) patients, who typically have complex and long-term care demands, contribute considerably to the high work pressure of primary care professionals (PCPs). To improve patient as well as provider experiences, it is crucial to take into account the PCPs’ perspective in designing health care strategies for HNHC patients. Therefore, this study aimed to create insight into PCPs’ experienced barriers and possible solutions with regards to person-centred, efficient care delivery to HNHC patients. Methods We conducted a qualitative study using focus group interviews with PCPs at a Dutch primary care group. A semi-structured interview guide was developed for the interviews. Qualitative content analysis was employed deductively by means of a categorisation matrix. The matrix was based on the components retrieved from the SELFIE framework for integrated care for multi-morbidity. Results Forty-two PCPs participated in five focus group interviews. Discussed barriers and solutions were related to the core of the SELFIE framework (i.e. the individual and environment), and particularly four of the six health system components in the framework: service delivery, leadership & governance, workforce, and technologies & medical products. Many discussed barriers revolved around the complex biopsychosocial needs of HNHC patients: PCPs reported a lack of time (service delivery), insufficiently skilled PCPs (workforce), and inefficient patient information retrieval and sharing (technologies & medical products) as barriers to adequately meet the biopsychosocial needs of HNHC patients. Conclusions This qualitative study suggests that primary care is currently insufficiently equipped to accommodate the complex biopsychosocial needs of HNHC patients. Therefore, it is firstly important to strengthen primary care internally, taking into account the experienced lack of time, the insufficient number of equipped PCPs and lack of inter-professional information retrieval and sharing. Secondly, PCPs should be supported in cooperating and communicating more efficiently with health services outside primary care to adequately deliver person-centred, efficient care. As a prerequisite, it is crucial to direct policy efforts at the design of a strong system of social and community services. In terms of future research, it is important to assess the feasibility and effects of re-designing primary care based on the provided recommendations.

The purpose of this study is to understand the course of costs over a 2-year period in a cohort of recently diagnosed fibromyalgia (FM) patients receiving different treatment strategies. Following the diagnosis, patients were randomly assigned to a multidisciplinary programme (MD), aerobic exercise (AE) or usual care (UC) without being aware of alternative interventions. Time between diagnosis and start of treatment varied between patients. Resource utilisation, health care costs and costs for patients and families were collected through cost diaries. Mixed linear model analyses (MLM) examined the course of costs over time. Linear regression was used to explore predictors of health care costs in the post-intervention period. Two hundred three participants, 90 % women, mean (SD) age 41.7 (9.8) years, were included in the cohort. Intervention costs per patient varied from €864 to 1392 for MD and were €121 for AE. Health care costs (excluding intervention costs) decreased after diagnosis, but before the intervention in each group, and increased again afterwards to the level close to the diagnostic phase. In contrast, patient and family costs slightly increased over time in all groups without initial decrease immediately after diagnosis. Annualised health care costs post-intervention varied between €1872 and 2310 per patient and were predicted by worse functioning and high health care costs at diagnosis. In patients with FM, health care costs decreased following the diagnosis by a rheumatologist. Offering patients a specific intervention after diagnosis incurred substantial costs while having only marginal effects on costs.

BackgroundReinforcing the gatekeeping role of general practitioners (GPs) by embedding specialist knowledge into primary care is seen as a possibility for stimulating a more sustainable healthcare system and avoiding unnecessary referrals to outpatient care. An intervention called Primary Care Plus (PC+) was developed to achieve these goals. The objective of this study is to gain insight into: (1) the content and added value of PC+ consultations according to stakeholders, and (2) patient satisfaction with PC+ compared to outpatient care.MethodsA feasibility study was conducted in the southern part of the Netherlands between April 2013 and January 2014. Data was collected using GP, medical specialist and patient questionnaires. Patient characteristics and medical specialty data were collected through the data system of a GP referral department.ResultsGPs indicated that they would have referred 85.4 % of their PC+ patients to outpatient care in the hypothetical case that PC+ was not available. Medical specialists indicated that about one fifth of the patients needed follow-up in outpatient care and 75.9 % of the consultations were of added value to patient care. The patient satisfaction results appear to be in favour of PC+.ConclusionPC+ seems to be a feasible intervention to be implemented on a larger scale, because it has the potential to prevent unnecessary hospital referrals. PC+ will be evaluated on a larger scale regarding the effects on health outcomes, quality of care and costs (Triple Aim principle).

Objective. To evaluate the substitution of specialized rheumatology nurses for rheumatologists in diagnosing fibromyalgia (FM).Methods. Referred patients with FM symptoms (n ‫؍‬ 193) were randomized to a study group diagnosed by a specialized rheumatology nurse (SRN group, n ‫؍‬ 97) or to a control group diagnosed by a rheumatologist (RMT group, n ‫؍‬ 96). SRN patients were seen within 3 weeks by a nurse who took structured history and initiated routine laboratory tests. During a 5-minute supervision session, the rheumatologist was informed by the nurse about medical history, performed a brief physical examination, and confirmed or rejected the nurse's diagnosis. RMT patients were seen by a rheumatologist after a regular waiting period of 3 months. Outcome measures were initial agreement between the nurse and rheumatologist in the SRN group, final diagnosis after 12-24 months of followup, patient satisfaction, and diagnostic costs. Results. The mean waiting time after randomization was 2.8 and 12.1 weeks in the SRN and RMT groups, respectively. Eight RMT patients cancelled their appointments because of the waiting time. Excellent agreement ( ‫؍‬ 0.91) between rheumatologists and nurses was found. After 12-24 months of followup, none of the initial diagnoses were recalled in either group. SRN patients were significantly more satisfied than RMT patients. Mean diagnostic costs were lower in the SRN group (€219) than in the RMT group (€281) (95% uncertainty interval €؊103, €؊20). Conclusion. Substituting specialized nurses for rheumatologists in the diagnostic process of FM is a trustworthy and successful approach that saves waiting time, provides greater patient satisfaction, and is cost-effective.

Realist evaluation (RE) is an emerging and promising research approach for evaluating integrated care, addressing what works, how, for whom, and in what circumstances. r The rich philosophical foundation of RE, critical realism, can help to systematically unravel an integrated care program's initial theory prior to implementation, as a first step within RE.r RE can be considered a robust methodological asset in integrated care research by facilitating a deeper level of insight into program functioning than traditional forms of evaluation do and by shaping a realistinformed monitoring and evaluation process. Context:The complexity of integrated care and the need for transferable evaluation insights ask for a suitable evaluation paradigm. Realist evaluation (RE), underpinned by the philosophy of critical realism, is a theory-driven approach that addresses what works, how, for whom, and in what circumstances. The current study illustrates the process needed for RE's first step: eliciting the initial program theory (IPT). The TARGET program, a Dutch primary care initiative